HESI 799 RN EXIT UPDATED EXAM QUESTIONS AND
ANSWERS MARKED A+
✔✔In preparing a diabetes education program, which goal should the nurse identify as
the primary emphasis for a class on diabetes self-management?
a. Prepare the client to independently treat their disease process
b. Reduce healthcare costs related to diabetic complications
c. Enable clients to become active participating in controlling the disease process
d. Increase client's knowledge of the diabetic disease process and treatment options. -
✔✔c. Enable clients to become active participating in controlling the disease process
Rationale: The primary goal of diabetic self- management education is to enable the
client to become an active participant in the care and control of disease process,
matching levels of self- management to the abilities of the individual client. The goal is
to place the client in a cooperative or collaborative role with healthcare professional
rather than (A)
✔✔To reduce staff nurse role ambiguity, which strategy should the nurse manager
implemented?
a. Confirm that all the staff nurses are being assigned to equal number of clients.
b. Review the staff nurse job description to ensure that it is clear, accurate, and
recurrent.
c. Assign each staff nurse a turn unit charge nurse on a regular, rotating basis.
d. Analyze the amount of overtime needed by the nursing staff to complete
assignments. - ✔✔b. Review the staff nurse job description to ensure that it is clear,
accurate, and recurrent.
Rationale: Role ambiguity occurs when there is inadequate explanation of job
descriptions and assigned tasks, as well as the rapid technological changes that
produce uncertainty and frustration. A and D may be implemented if the nurse manager
is concerned about role overload, which is the inability to accomplish the tasks related
to one's role. C is not related to ambiguity.
✔✔The nurse is assisting a new mother with infant feeding. Which information should
the nurse provide that is most likely to result in a decrease milk supply for the mother
who is breastfeeding?
a. Supplemental feedings with formula
b. Maternal diet high in protein
c. Maternal intake of increased oral fluid
d. Breastfeeding every 2 or 3 hours. - ✔✔Supplemental feedings with formula
,Rationale: Infant sucking at the breast increases prolactin release and proceeds a
feedback mechanism for the production of milk, the nurse should explain that
supplemental bottle formula feeding minimizes the infant's time at the breast and
decreases milk supply. B promotes milk production and healing after delivery. C support
milk production. C is recommended routine for breast feeding that promote adequate
milk supply.
✔✔Which assessment is more important for the nurse to include in the daily plan of
care for a client with a burned extremity
a. Range of Motion
b. Distal pulse intensity
c. Extremity sensation
d. Presence of exudate - ✔✔Distal pulse intensity
Rationale: Distal pulse intensity assesses the blood flow through the extremity and is
the most important assessment because it provides information about adequate
circulation to the extremity. Range of motions evaluates the possibility of long term
contractures sensation. C evaluates neurological involvement, and exudate. D provides
information about wound infection, but this assessment does not have the priority of
determining perfusion to the extremity.
✔✔An elderly client with degenerative joint disease asks if she should use the rubber jar
openers that are available. The nurse's response should be based on which information
about assistive devices?
a. They can contribute to increased dependency
b. They decrease the risk for joint trauma
c. They promote muscle strength
d. They diminish range of motion ability. - ✔✔They decrease the risk for joint trauma
Rationale: Assistive devices of this kind are very beneficial in reducing joint trauma(B)
caused by excessive twisting. These devices promote independence, rather that
increasing dependency
✔✔When assessing a 6-month old infant, the nurse determines that the anterior
fontanel is bulging. In which situation would this finding be most significant?
a. Crying
b. Straining on stool
c. Vomiting
d. Sitting upright. - ✔✔Sitting upright.
Rationale: The anterior fontanel closes at 9 months of age and may bulge when venous
return is reduced from the head, but a bulging anterior fontanel is most significant if the
infant is sitting up and may indicated an increase in cerebrospinal fluid. Activities that
, reduce venous return from the head, such as crying, a Valsalva maneuver, vomiting or
a dependent position of the head, cause a normal transient increase in intracranial
pressure.
✔✔A client with angina pectoris is being discharge from the hospital. What instruction
should the nurse plan to include in this discharge teaching?
a. Engage in physical exercise immediately after eating to help decrease cholesterol
levels.
b. Walk briskly in cold weather to increase cardiac output
c. Keep nitroglycerin in a light-colored plastic bottle and readily available.
d. Avoid all isometric exercises but walk regularly. - ✔✔Avoid all isometric exercises,
but walk regularly
Rationale: Isometric exercise can raise blood pressure for the duration of the exercise,
which may be dangerous for a client with cardiovascular disease, while walking
provides aerobic conditioning that improves ling, blood vessel, and muscle function.
Client with angina should refrain from physical exercise for 2 hours after meals, but
exercising does not decrease cholesterol levels. Cold water cause vasoconstriction that
may cause chest pain. Nitroglycerin should be readily available and stored in a dark-
colored glass bottle not C, to ensure freshness of the medication.
✔✔What is the priority nursing action when initiating morphine therapy via an
intravenous patient-controlled analgesia (PCA) pump?
a. Assess the client's ability to use a numeric pain scale
b. Initiate the dosage lockout mechanism on the PCA pump
c. Instruct the client to use the medication before the pain become severe
d. Assess the abdomen for bowel sounds - ✔✔Initiate the dosage lockout mechanism
on the PCA pump
Rationale: Morphine depress respiration, so ensuring that the client cannot overdose on
the medications
✔✔While undergoing hemodialysis, a male client suddenly complains of dizziness. He
is alert and oriented, but his skin is cool and clammy. His vital signs are: heart rate 128
beats/minute, respirations 18 breaths per minute, and blood pressure 90/60. Which
intervention should the nurse implement first?
a. Raise the client's legs and feet
b. Administer 250 ml saline bolus
c. Decrease blood flow from dialyzer
d. Stop the hemodialysis procedure. - ✔✔Raise the client's legs and feet
Rationale: To raise the client's blood pressure is the most immediate and easiest
intervention for the nurse to implement. B and C should be done asap to add volume to
ANSWERS MARKED A+
✔✔In preparing a diabetes education program, which goal should the nurse identify as
the primary emphasis for a class on diabetes self-management?
a. Prepare the client to independently treat their disease process
b. Reduce healthcare costs related to diabetic complications
c. Enable clients to become active participating in controlling the disease process
d. Increase client's knowledge of the diabetic disease process and treatment options. -
✔✔c. Enable clients to become active participating in controlling the disease process
Rationale: The primary goal of diabetic self- management education is to enable the
client to become an active participant in the care and control of disease process,
matching levels of self- management to the abilities of the individual client. The goal is
to place the client in a cooperative or collaborative role with healthcare professional
rather than (A)
✔✔To reduce staff nurse role ambiguity, which strategy should the nurse manager
implemented?
a. Confirm that all the staff nurses are being assigned to equal number of clients.
b. Review the staff nurse job description to ensure that it is clear, accurate, and
recurrent.
c. Assign each staff nurse a turn unit charge nurse on a regular, rotating basis.
d. Analyze the amount of overtime needed by the nursing staff to complete
assignments. - ✔✔b. Review the staff nurse job description to ensure that it is clear,
accurate, and recurrent.
Rationale: Role ambiguity occurs when there is inadequate explanation of job
descriptions and assigned tasks, as well as the rapid technological changes that
produce uncertainty and frustration. A and D may be implemented if the nurse manager
is concerned about role overload, which is the inability to accomplish the tasks related
to one's role. C is not related to ambiguity.
✔✔The nurse is assisting a new mother with infant feeding. Which information should
the nurse provide that is most likely to result in a decrease milk supply for the mother
who is breastfeeding?
a. Supplemental feedings with formula
b. Maternal diet high in protein
c. Maternal intake of increased oral fluid
d. Breastfeeding every 2 or 3 hours. - ✔✔Supplemental feedings with formula
,Rationale: Infant sucking at the breast increases prolactin release and proceeds a
feedback mechanism for the production of milk, the nurse should explain that
supplemental bottle formula feeding minimizes the infant's time at the breast and
decreases milk supply. B promotes milk production and healing after delivery. C support
milk production. C is recommended routine for breast feeding that promote adequate
milk supply.
✔✔Which assessment is more important for the nurse to include in the daily plan of
care for a client with a burned extremity
a. Range of Motion
b. Distal pulse intensity
c. Extremity sensation
d. Presence of exudate - ✔✔Distal pulse intensity
Rationale: Distal pulse intensity assesses the blood flow through the extremity and is
the most important assessment because it provides information about adequate
circulation to the extremity. Range of motions evaluates the possibility of long term
contractures sensation. C evaluates neurological involvement, and exudate. D provides
information about wound infection, but this assessment does not have the priority of
determining perfusion to the extremity.
✔✔An elderly client with degenerative joint disease asks if she should use the rubber jar
openers that are available. The nurse's response should be based on which information
about assistive devices?
a. They can contribute to increased dependency
b. They decrease the risk for joint trauma
c. They promote muscle strength
d. They diminish range of motion ability. - ✔✔They decrease the risk for joint trauma
Rationale: Assistive devices of this kind are very beneficial in reducing joint trauma(B)
caused by excessive twisting. These devices promote independence, rather that
increasing dependency
✔✔When assessing a 6-month old infant, the nurse determines that the anterior
fontanel is bulging. In which situation would this finding be most significant?
a. Crying
b. Straining on stool
c. Vomiting
d. Sitting upright. - ✔✔Sitting upright.
Rationale: The anterior fontanel closes at 9 months of age and may bulge when venous
return is reduced from the head, but a bulging anterior fontanel is most significant if the
infant is sitting up and may indicated an increase in cerebrospinal fluid. Activities that
, reduce venous return from the head, such as crying, a Valsalva maneuver, vomiting or
a dependent position of the head, cause a normal transient increase in intracranial
pressure.
✔✔A client with angina pectoris is being discharge from the hospital. What instruction
should the nurse plan to include in this discharge teaching?
a. Engage in physical exercise immediately after eating to help decrease cholesterol
levels.
b. Walk briskly in cold weather to increase cardiac output
c. Keep nitroglycerin in a light-colored plastic bottle and readily available.
d. Avoid all isometric exercises but walk regularly. - ✔✔Avoid all isometric exercises,
but walk regularly
Rationale: Isometric exercise can raise blood pressure for the duration of the exercise,
which may be dangerous for a client with cardiovascular disease, while walking
provides aerobic conditioning that improves ling, blood vessel, and muscle function.
Client with angina should refrain from physical exercise for 2 hours after meals, but
exercising does not decrease cholesterol levels. Cold water cause vasoconstriction that
may cause chest pain. Nitroglycerin should be readily available and stored in a dark-
colored glass bottle not C, to ensure freshness of the medication.
✔✔What is the priority nursing action when initiating morphine therapy via an
intravenous patient-controlled analgesia (PCA) pump?
a. Assess the client's ability to use a numeric pain scale
b. Initiate the dosage lockout mechanism on the PCA pump
c. Instruct the client to use the medication before the pain become severe
d. Assess the abdomen for bowel sounds - ✔✔Initiate the dosage lockout mechanism
on the PCA pump
Rationale: Morphine depress respiration, so ensuring that the client cannot overdose on
the medications
✔✔While undergoing hemodialysis, a male client suddenly complains of dizziness. He
is alert and oriented, but his skin is cool and clammy. His vital signs are: heart rate 128
beats/minute, respirations 18 breaths per minute, and blood pressure 90/60. Which
intervention should the nurse implement first?
a. Raise the client's legs and feet
b. Administer 250 ml saline bolus
c. Decrease blood flow from dialyzer
d. Stop the hemodialysis procedure. - ✔✔Raise the client's legs and feet
Rationale: To raise the client's blood pressure is the most immediate and easiest
intervention for the nurse to implement. B and C should be done asap to add volume to
